As the Chairman of Planning Commission’s High Level Group on Universal Health Coverage, Dr Srinath Reddy has set new goals for healthcare. The President of Public Health Foundation of India (PHFI), in a free wheeling chat with Shalini Gupta, talks about how India can get its act together in public health
What is your vision for Public Health Foundation of India (PHFI) and what efforts are underway to realise the same?
| Dr Srinath Reddy |
The reason I gave up my Chair of Cardiology at All India Institute of Medial Sciences (AIIMS) and came to PHFI is because I believe that India needs to build a lot of capacity in public health. We need to create institutes dedicated to capacity building, reorient existing courses at medical institutes and colleges towards public health, do good public health research which is policy and programme relevant and promote interdisciplinary public health education.
We are delivering short-term training courses to healthcare professionals since the last four years through our institutes in Delhi, Hyderabad, Bhubaneshwar and Gandhinagar. We plan to start a fifth centre in Shillong soon. Our flagship programme, Diploma in Public Health is closely aligned to National Rural Health Mission (NRHM) as a part of which we are training a number of district and block level medical officers.
Our Health Communication Division along with Health Systems Support unit is working closely with Central and State governments to help strengthen the health systems in terms of design and operation. Engineers at the Affordable Technologies unit are trying to find ways to increase the capacity of non-physician providers to point of care diagnostics at primary healthcare centres.
Swasthya slate, a tablet computer and an android phone rolled into one, that can help diagnose diseases on the spot is being tested out in Andhra Pradesh. In a nutshell, we are working on multiple fronts, right from education to technology to advocacy for public health.
Government funding in healthcare is perhaps the lowest in India. It is set to increase towards the end of the 12th plan after the recommendations made by the high level expert group led by you. How is it going to help?
Social determinants of health such as water, sanitation, nutrition and environment are important but public health financing is pivotal to provide financial entitlement in terms of purchase of services so that the out of pocket expenditure is taken care of. It is also needed for expansion of health workforce- for building better infrastructure and provision of essential drugs free of cost. Therefore, we proposed a minimum of 2.5 per cent of GDP towards healthcare for present plan period and three per cent by the next plan period.
However, a financial protection mechanism alone will not suffice unless it is backed by a delivery mechanism which is accessible and efficient. This, in turn, demands infrastructure, a competent motivated health workforce, equipment, drugs, vaccines and technologies alongwith a managerial system which ensures best utilisation of all available resources: human and financial. The approach has to take into account a package of services, not piecemeal.
Unfortunately our system has had defects in each and every one of these. A weak public sector infrastructure and a severely constrained health workforce both in numbers and skills further compounds the problem. We need to set right all of this.
Public financing thus would only solve part of the problem then?
Even with increased public funding in healthcare, there would be little or no absorption of these funds in the absence of adequate number of doctors and nurses, hence building the capacity of the health system is important.
Our view is that primary healthcare both in rural and urban areas need not be doctor intensive. Substantial number of non-physician health providers, like trained community health workers, auxiliary nurse midwives (ANMs), male multi-purpose health workers, mid-level health workers or even AYUSH practitioners with bridge training can create a cannon of mid-level health workers suited to be positioned at sub centres. These sub centres are functioning as static centres with only one auxiliary nurse midwife (ANM).
Each sub-centre should have two ANMs, one multi-purpose male health worker, one mid-level health worker, one lab technician cum dispenser and this should in turn become an outreach facility that can cover 3000-5000 people in remote areas. Such a system ensures preventive healthcare right at the primary level.
So basically a bottoms up approach to healthcare starting at the district level?
We need to strengthen district hospitals, make them training centres for new medical and nursing colleges and courses such as Bachelors of Community Health.
People trained here would be well acquainted with primary and secondary healthcare and well equipped to handle all problems at the district level reducing the dependency on tertiary care (corporate hospital or medical college). Creating referral linkages from primary healthcare to secondary to tertiary would help build a credible, coherent, well-organised system which is currently fragmented.
In districts where there are still gaps, public health providers can be contracted on a payment basis to perform the same services under the UHC system on terms set by the public sector. This has to be decided by the district health system manager. The idea is not to use private sector as a substitute to the public sector but as a supplement to it, where the public sector needs some additional hands.
How do you see provision of essential drugs for free, augmenting the cause?
Providing essential drugs free of cost helps reduce out of pocket expenditure, most of which comes from outpatient care and medicines. Recently, the Government has decided to provide drugs for TB for free, but the ambit of such drugs needs to be increased. Free distribution of drugs through public facilities helps increase public trust in such facilities, examples of which can be seen in Rajasthan and Tamil Nadu. The state can use its power for pooled procurement of unbranded generics or generics at low cost, eliminate middlemen, so that drug manufacturers will be able to reduce the rates thus reducing dependence on branded drugs, while ensuring quality. An essential healthcare package should be available to every citizen free of cost, given that current insurance schemes do not pay for outpatient care, primary care and supply of medicines over a long time. While the government has been the major player and is doing good through Rashtriya Swasthya Bima Yojana (RSBY), Arogyashree and other schemes, the focus has to be less on funding tertiary care and secondary care, but more on improving overall population health outcomes. Integration of these schemes into the overall framework of Universal Health Coverage (UHC) needs to worked at. Primary care has been neglected so far, even in urban areas, that trend needs to be reversed, it has to be the first priority.
So, this package would only cover primary healthcare?
It should cover secondary care alongwith some elements of tertiary care. For e.g., a child with leukaemia should not be denied treatment, as a young man with a snakebite who may die without ventilator support in a village and also a woman who has had a mishandled delivery with a ruptured uterus, such elements from tertiary care need to be fitted into the essential healthcare package. The money needs to come from tax-based financing, additional amount can be paid by employer based insurance or private insurance if elements outside of this package need to be purchased.
What is your view on government regulations and their role in healthcare?
Recently, Ministry of Health is ordering drug quality to be tested not only from samples lifted from the shops but also from manufacturing hubs, however, we need more drug testing labs across the country. The Clinical Establishment Act is only adopted by four states, even that still has some lacunae. Drug regulation is relatively on the weaker side, particularly w.r.t. state drug authorities, so we need to strengthen our drug regulatory system. For all common clinical conditions, standard management guidelines should be evolved through expert consensus and become mandatory. Accountability should improve so that people can address their grievances at the block level. A public health cadre and health management cadre should be created. We also need a spirit of Partnerships for Public Purpose (PPP) wherein we define the public purpose, say what needs to be delivered, who will deliver it, find complimentary roles for the parties involved and hold them accountable.
What are the public health challenges of India? What role can preventive healthcare play?
We have a mixed challenge for years to come. While infectious diseases such as malaria, HIV, TB, neglected tropical diseases and a lot of parasitic diseases inflict the population on one hand, NCDs are galloping fast expanding their reach to rural areas. Better quality of water, sanitation and environment will prevent a lot of infectious diseases. Fundamentally, we need to lay the foundations of good health across the whole life span of an individual. Prevention can be done at different levels at the onset preventing risk acquisition, then when one has acquired the risk factors and is on the verge of developing the disease and finally preventing those with the disease from developing complications or recurrence. At the same time we also need to gear up our health system for early detection and management of risk.
What should be the approach to achieve preventive healthcare?
A multi-sector approach is needed where in we work with sectors such as water, sanitation, nutrition urban design, agriculture and food processing etc.
Policies and programmes in other sectors have quite an impact on health. So just as we are aligning policies towards environment to assess the environmental impact, it is also important to align those policies towards health, be it reducing the amount of unhealthy fats in processed foods or ensuring greater production and availability of fruits and vegetables. There is health beyond healthcare.
Let me give you an analogy. In automobile industry, if cars are going out of order, we try and build sturdier models, then we see if road conditions are good, or have potholes, try and repair them and finally educate drivers for better repair of cars.
Building a car repair shop at every corner does not help. Similarly, human beings can also be built sturdier through better nutrition, creating better environmental conditions through safe water, better urban planning and finally make people health aware. Building hospitals and nursing homes everywhere is not the solution.
How do you envision the country’s healthcare system in the coming years?
At the end of 12th five year plan, I would like to see most states investing heavily alongwith Central government support in primary healthcare and out of pocket expenditure come down to 50 per cent from the current 71 per cent, a drop in the indicators such as infant mortality and maternal mortality, a substantial improvement in child under-nutrition and anaemia in adolescent girls, essential medicines given free across the country, public health cadre in every state along with the health management cadre and a strong regulatory system set up to ensure appropriate care delivery and accountability.
I do not expect all of UHC to be implemented in the next five years, that will take 10 years, but I would like to see us moving quite well along that path.